1346212693 NPI number — AZIZUR RAHMAN MD

Table of content: AZIZUR RAHMAN MD (NPI 1346212693)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346212693 NPI number — AZIZUR RAHMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RAHMAN
Provider First Name:
AZIZUR
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346212693
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
695 N PERRYVILLE RD STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKFORD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61107-6225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-904-6011
Provider Business Mailing Address Fax Number:
815-904-6171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
695 N PERRYVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61107-6225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-904-6011
Provider Business Practice Location Address Fax Number:
815-904-6171
Provider Enumeration Date:
02/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  O36129423 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4134410 . This is a "TENNCARE SELECT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4134410 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3843144 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4134410 . This is a "BLUE CROSS ADVANTAGE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: P01320105 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 621298175 . This is a "DEFAULT" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 371909283 . This is a "TRICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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